Provider Demographics
NPI:1043217599
Name:MEULENBERG, DANIEL JACK (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JACK
Last Name:MEULENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 N 3RD AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1594
Mailing Address - Country:US
Mailing Address - Phone:208-263-5527
Mailing Address - Fax:208-263-4580
Practice Address - Street 1:606 N 3RD AVE STE 101
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1594
Practice Address - Country:US
Practice Address - Phone:208-263-1435
Practice Address - Fax:208-263-7812
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002792600Medicaid
ID1125104Medicare ID - Type Unspecified